Key Facts

Remote From:

Full time

Senior (5-10 years)

English

Hard Skills

ICD Coding (ICD-9/ICD-10) Medical Insurance Claims CPT Coding Claims And Litigation Management Microsoft Access Medical Record Management Medical Necessity Fraud Detection Billing Cost Benefit Analysis Diagnosis Codes Claims And Litigation Management Daily Production Reports Customer Centricity Continuous Training

Other Skills

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Record Keeping
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Computer Literacy
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Accountability
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Communication
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Analytical Skills
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Time Management
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Teamwork

Roles & Responsibilities

Minimum 5 years of medical claims analysis experience (including dental and vision).
Strong analytical skills and knowledge of computer systems; proficiency with CPT and ICD-9 coding terminology.
Continuing education in areas affecting group health and welfare plans; HIPAA/HITECH training as applicable.
High School Diploma required; college degree preferred.

Requirements:

Independently review and analyze health care claims for reasonableness of cost, medical necessity, and fraud; determine plan benefits and payment level; authorize payment, partial payment, or denial.
Communicate with providers to negotiate discounts; log claims in Access database; document and maintain notes in QicLink and alliedbenefit systems; review billed codes for irregularities and medical necessity.
Review client-specific plan terms; collect and analyze physician notes, hospital records, and police reports; ensure compliance with privacy laws (HIPAA/HITECH).
Collaborate with other entities for claim evaluations; assist teammates; attend required continuing education; review and follow up on Suspended Claim Reports.

Allied Benefit Systems, LLC

About Allied Benefit Systems, LLC

Allied is a national healthcare solutions company that works with organizations who choose to take control of their healthcare. We customize employer self-insurance benefits to align with individual choice and organizational need while integrating medical management innovations and cost-control strategies. With healthcare designed for people, employers never have to choose between price and the best-fit insurance products to protect employees and their families. Allied’s philosophy is to create a culture of health for our member organizations and their employees beyond simple, medical health. We integrate administrative services, care solutions and analytics to achieve better clinical, behavioral and social patient outcomes. Allied’s programs and benefit services are designed and structured to infuse value on every front – for employers and HR departments, for plan members and their families, for healthcare providers, and for us. We’re in this together, committed to your future.

Company type: Unicorn

Founded: 2018

Company size: 501 - 1000

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Job description

POSITION SUMMARY

Determining the proper payment (if any) of medical claims by group health plans, based upon specific knowledge and application of each client’s customized plan(s).

ESSENTIAL FUNCTIONS

Independently review and analyze health care claims for: 1) reasonableness of cost; 2) medically unnecessary treatment by physicians and hospitals; and 3) fraud.
Determine whether a health plan provides benefits in connection with the claim submitted and the level of benefits to be paid to the provider.
Contact providers to negotiate discounts.
Log claims negotiated in Access database and create weekly summary reports.
Review and understand the terms and conditions of each clients’ customized plans.
Understand and comply with all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
Request, review and analyze any physician notes, hospital records or police reports.
Consult with other entities who can offer additional evaluation of a claim.
Process claims in the QicLink System.
Review, analyze and add applicable notes to the QicLink System.
Document all information gathered in available systems as needed, including the QicLink System and alliedbenefit.com.
Review billed procedure and diagnosis codes on claims for billing irregularities.
Analyze claims for billing inconsistencies.
Review and analyze specific procedure and diagnosis codes for medical necessity.
Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
Review Suspended Claim Reports and follow up on open issues.
Assist and support other team members as needed and when requested.
Attend continuing education classes as required, including but not limited to HIPAA training.
Other duties as assigned.

POSITION QUALIFICATIONS

SKILLS & ABILITIES

All applicants must have strong analytical skills and knowledge of computer systems and CPT and ICD-9 coding terminology. Continuing education in all areas affecting group health and welfare plans is required.

COMPETENCIES
Job Knowledge
Time Management
Accountability
Communication
Initiative
Customer Focus

EXPERIENCE

Applicants must have a minimum of 5 years of medical claims analysis experience (including dental and vision claims analysis).

EDUCATION

High School Diploma, College and Advanced Degrees Preferred

PHYSICAL DEMANDS
Ability to work with computer-based programs for extended periods of time.

WORK ENVIRONMENT
Remote

Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.

The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.

Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life & Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.

Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.